Casey
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
PATIENT REGISTRATION
3851 Katella Avenue, Suite 150
Los Alamitos, CaLifornia 90720
Telephone: 562.314.1400
Fax: 562.431.0564
www.losalamitosortho.com
T
hank you for choosing Los Alamitos Orthopaedic Medical & Surgical Group. We look forward
to your first visit with us. In order to ensure that we do the best job possible and address all your
specific issues, it would be very helpful if you would please complete this registration packet before
your initial visit.
We have included a checklist for your convenience to assist you with all the various forms and
information needed. Be assured that all the information provided will assist us in assessing
your needs.
Please remember to bring your insurance card, co-pay and any authorizations and referrals that
apply to your visit. It would also be helpful to bring Xrays, MRI results and or any medical reports
available.
If you have any questions, please feel free to call our office for assistance.
Thank you,
Los Alamitos Orthopaedic Medical & Surgical Group
Casey
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
PATIENT REGISTRATION
3851 Katella Avenue, Suite 150
Los Alamitos, CaLifornia 90720
Telephone: 562.314.1400
Fax: 562.431.0564
www.losalamitosortho.com
Patient Registration (Check List)
Please make sure you have completed ALL of the following forms and remember to bring them to your first
appointment.
1. Patient Registration - administrative and insurance information (signature needed)
2. Initial Consultation - please document your problem as specifically as possible
3. Privacy Notice Acknowlegement (3 pages) - government policies concerning privacy (signature needed)
4. Permission for Phone Messages - permission to leave messages on your phone (signature needed)
5. Financial Policy - clarification of financial responsibilities (signature needed)
6. Office Policy - explanation of our office policies
7. Medical Records - authorization for the doctor to release/receive information (signature needed)
8. Pain Medication Agreement - policies on dispensing of medication (signature needed)
Along with this registration packet, please also remember to bring:
1. Insurance card with any co-payment, co-insurance or deductible payments
2. Authorizations, referrals, Xrays, CDs, MRI
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
1. PATIENT REGISTRATION
Patient Name:
Last
First
Middle Initial
Nickname
Home Address:
StreetApt#
City
StateZip
Home Phone:
Cell Phone:
Email:
Emergency Contact:
Gender: Emergency Phone:
Male
Marital Status:
Female
Single
Married
Birthdate:
Separated
Age:
Divorced
Widow/er
Social Security#:
Primary Care Physician:
Referred by (doctor/patient/friend):
Patient’s Employer/School:
Reason for today’s visit:
INSURANCE INFORMATION:
Primary Insurance:
Phone:
Plan ID Number:
Group Number:
Insurer’s Name:
Insurer’s Social Security#:
PPO In Network
PPO Out of Network
Commercial/Indemnity
Primary Insurance:
Phone:
Plan ID Number:
Group Number:
Insurer’s Name:
Insurer’s Social Security#:
PPO In Network
PPO Out of Network
Commercial/Indemnity
Insurance Yearly Effective Date:
Has the Deductible been met this year?
Medicare
Medicare
Deductible Amount: $
Yes
No
CoPay for Office Visits: $
What is remaining? $
CoInsurance%: $
I request that payment of authorized Medicare or insurance benefits be made to my physician on my behalf for any services furnished to me by any of the
physicians at Los Alamitos Orthopaedic Medical and Surgical Group. I authorize any holder of medical information about me to release to my insurance any
information needed to determine these benefits. I authorize treatment of the person named above and agree to pay all fees and charges for such treatment,
and I accept financial responsibility for non-covered services.
SignatureDate
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
2. INITIAL CONSULTATION
Paul J. Casey M.D.
3851 Katella Avenue, Suite 150
Los Alamitos, Caifornia 90720
Telephone: 562.314.1400
Fax: 562.431.0564
www.losalamitosortho.com
NAME:
DATE:
Date of Injury:
Chief Complaint:
Age:
Dominant Hand:
Right Left
Gender:
Male Female
Occupation:
Previous injuries to this area (Hand/Wrist/Forearm/Elbow):
Medications:
Past Surgical History:
Social History: Smoking:
No
Yes
Allergies:
Previous Illnesses/Past Medical History:
Hospitalizations:
Immunizations (UTD):
Quantity:
Alcohol:
No
Yes
Quantity:
page 1 of 3
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
3. PRIVACY NOTICE
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your confidentiality is maintained my restricting access only to employees who need access to your PHI in order to process services. Also, we have
implemented appropriate physical, electronic and procedural safeguards to protect you PHI against any unauthorized use or disclosure. Our staff is
required to complete and annually review a training program designed to protect you PHI. Although there are many safeguards to protect your PHI,
there are some instances where Federal and State laws allow us to use/disclose your information without your consent.
These are:
1. To provide your health care services.
2. To bill and collect payments for the health care services provided.
3. To provide you with treatment alternatives.
4. To inform you about health benefits and services.
5. To remind you of your appointments.
6. To complete health care operations such as to resolve an appeal or a grievance.
7. When required by law.
8. For public health activities.
9. For health oversight activities.
10. For reports about child and other types of abuse or neglect or domestic violence.
11. For lawsuits or other legal purposes.
12. For law enforcement purposes.
13. To report to coroners, medical examiners or funeral directors.
14. For tissue or organ donations.
15. For research.
16. To avert a serious threat to the health or safety or you or others.
17. For national security and intelligence/military activities.
18. In connection with services provided under workers’ compensation laws.
19. To family members or persons who are involved in your care or payment of care.
20. To create a directory that includes your name, your location at the facility, your general condition and your religious preferences when you are in an affiliated hospital.
You may agree or object to this disclosure. If you cannot agree or object because you are incapacitated or otherwise unavailable, we will use our
professional judgment. If you are a parent, you may control your minor child’s PHI. There are some cases when we are permitted or even required by the
law to deny your access to your child’s PHI, such as when your child can legally consent to medical services without your permission. There are some
types of PHI, such as HIV test results or mental health information, which are protected by stricter laws. However, even this PHI may be used or disclosed
without your written authorization if required or permitted by law. All other uses and disclosures of your PHI require your written authorization. If you
need an arbitration form, we will send you one for you or your personal representative to complete. When you receive the form, please fill it out and send
it to the following address:
Attention: Carol Olivarez, Privacy Officer
Los Alamitos Orthopaedic Medical and Surgical Group
3851 Katella Avenue, Suite 150
Los Alamitos, California 90720
page 2 of 3
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
3. PRIVACY NOTICE
NOTICE OF PRIVACY PRACTICES (continued)
You may revoke or modify your authorization at any time by writing to us at the same address. Please note that your revocation or modification may not be
effective in some circumstances, such as when you have already taken action relying your authorization. You also have the right to review and copy any of
your PHI that we possess. If you wish to see your PHI, please write to us and we will tell you when and where you can review your PHI in our possession
within our normal business hours. If you would like a copy of the information we have, please write to us at the same address. If we provide you with a
copy, we may charge a reasonable administrative fee for copying your PHI to the extent permitted by applicable law. If we deny your request for review or
copy of your PHI, we will explain the reason in writing. If we do not have your PHI, but know who does, we will tell you whom to contact. If you wish to
have your PHI corrected or updated, please write to us and tell us what you want changed and why. We will respond to you in writing, whether accepting
or denying your request. If we deny your request, we will explain why. You may also send us an addendum that is no longer than 250 words in length for
each item you believe is incorrect. Please clearly indicate that you want the addendum to be included in your PHI. We will attach your addendum to the
record(s) of your PHI. Your amended PHI will be available for your review upon request. You have the right to request an accounting of certain disclosures
that we make of your PHI by writing to us. Please note that certain disclosures, such as those made for treatment, payment, or health care operations,
need not be included in the accounting we provide to you. We will respond to your request within a reasonable period of time, but no later than 60 days
after we receive your written request. You have the right to request and receive a paper copy of this Notice. You have the right to restrict restrictions on
how we use and disclose you PHI for our treatment, payment and health care operations. All requests must be made in writing. Upon receipt, we will review
your request and notify you whether we have accepted or denied your request and notify you whether we have accepted or denied your request. Please
note that we are not required to accept your request for restriction. Your PHI is critical for providing you with quality health care. We believe we have
taken the appropriate safeguards and internal restrictions to protect your PHI, and that additional restrictions may be harmful to your care. You have the
right to request that we provide your PHI to you in a confidential manner. For example, you may request that we send your PHI by alternate means, (e.g.
sending you a sealed envelope, rather than a postcard) or to an alternate address (e.g. calling you at a home address). We will accommodate any reasonable requests, unless they are administratively too burdensome, or prohibited by law. We must follow the privacy practices set forth in this Notice while in
effect. If you have any questions about this Notice, wish to exercise your rights, or file a complaint, please direct your inquires to:
Carol Olivarez, Privacy Officer
Los Alamitos Orthopaedic Medical and Surgical Group
3851 Katella Avenue, Suite 150
Los Alamitos, California 90720
You may contact your Health Plan or the California Department of Managed Care with your concerns as well. You also have the right to directly
complain to the Secretary of the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint against
us. We will use and disclose your PHI to the fullest extent authorized by law. We reserve the rights as expressed in this Notice. We reserve the right to
revise our privacy practices consistent with the law and make them applicable to your entire PHI we possess, regardless of when it was received or created.
If we make material or important changes to our privacy practices, we will promptly revise our Notice. Unless law requires the changes, we will not
implement material changes to our privacy practices before we revise our Notice. You may request updates to this Notice at any time.
Effective: June 1, 2004
page 3 of 3
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
3. PRIVACY NOTICE
NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT
We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record.
We will not disclose your records to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your
record or get more information about it by contacting the administrator of the location at which you have been treated. Please call the main
office phone number and ask for the administrator.
Our Notice of Privacy Practice describes in more detail how your health information may be used and disclosed, and how you can access your
information.
By my signature below I acknowledge receipt of the Notice of Privacy Practices.
Patient or legally authorized individual signature
Date
Printed name if signed on behalf of the patient
Relationship
(parent, legal guardian, personal representative)
This form will be retained in your medical record
Time
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
4. PHONE PERMISSION
PERMISSION TO LEAVE PHONE MESSAGES
Dear Patient:
HIPPA privacy guidelines prevent us from leaving messages for you regarding appointments or any other medical matter.
In order to efficiently communicate with you regarding appointment confirmations, changes or availability please sign below,
thereby giving us permission to leave a message on your answering machine, service or with a family member.
This waiver will apply only to messages regarding your appointment(s) or the need for the Doctors or their staff to speak with you
regarding procedures or results. No other medical information will be communicated.
I give permission for the Doctor’s or their staff to leave phone messages with:
Family members:
YES
NO
Answering machine/service:
YES NO
Patient’s Name (PRINT)
Patient’s Signature
Date
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
5. FINANCIAL POLICY
It is important to clarify our financial policy with each patient. This prevents misunderstanding and unnecessary hard feelings.
We make every effort to keep the cost of medical care down.
If you have insurance, as a courtesy we will bill the insurance company for you. Please understand that insurance policies represent an
agreement between you and your insurance company. You are responsible for the payment of your bill regardless of the status of your claim.
All patient co-payments and coinsurance are to be paid in full at the time services are rendered. Cash, check, Visa and Mastercard are
accepted. Telephone verification of your insurance coverage does not guarantee the claim will be paid. If you are dissatisfied with your
insurance company’s processing or payment of your claim, it will be your responsibility to arbitrate this matter with them. We will be glad to
supply you with a copy of the claim for arbitration. Should your insurance payments for claims be sent directly to you, whether primary or
secondary insurance companies, this should be used to pay outstanding charges for which you are financially responsible. Please desposit the
insurance check and send us a personal check or forward the insurance check as soon as possible.
Surgical Fees
The insurance company will be billed following surgery; however the patient responsibility portion will be due and payable at your first
post-operative office visit. At your request, an estimate of those fees will be made for you prior to your surgery. This will only be an estimate
based on the expected procedures and services performed. If the insurance company does not pay for the service provided it is the patient’s
responsibility to pay the balance within 30 days from the date of surgery.
Insurance Contracts and our office
Contracts between the insurance companies and our office change continually. You may call our office to see if your insurance is currently
accepted. We are NOT contracted with Medi-Cal. You will be notified by mail if we no longer accept your insurance. You have the option at that
time to continue treatment with our physicians by accepting all financial responsibility for your medical treatment or you may have your care and
medical records transferred to another physician of your choice.
Returned Check Policy
A $25.00 fee will be charges for all returned checks.
Payment by cashier’s check or money order will be required to replace the dishonored check.
I have read the above financial policy and understand and accept my responsibilities as a patient.
SignedDate
WitnessedDate
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
6. OFFICE POLICY
OFFICE HOURS
Monday though Thursday – 8:00 am - 5:00 pm
Fridays – 8:00 am - 4:00 pm
Closed for lunch (12:00 - 1:30)
DIRECTIONS
From the 405 Fwy: exit Seal Beach Blvd. Go east to Katella. Turn right on Katella. Turn left on Kaylor Street. The parking entrance will be on your
right.
From 605 Fwy: exit at Katella/Willow. Go south on Katella. Follow Katella approximately 1/2 mile. Turn left on Kaylor Street. The parking entrance
will be on your right.
APPOINTMENT POLICY
In order to provide our patients with timely scheduling options, the following office policies are now in place at our office.
Please become familiar with them.
Changes to Appointments:
We require a minimum of 24 hours notice to change the time or date of your appointment. Please contact the scheduling desk to request a change.
If you are delayed and cannot be on time for your appointment kindly call the office. Please be aware that it may not be possible to see your
Doctor that same day however, we will make every effort to do so.
Cancellations and No Shows:
Patients will be charged $25.00 for each “No Show” or cancellation not made at least 24 hours before the scheduled appointment.
FORMS COMPLETION
There is a $25.00 form fee that applies to outside forms requested for completion by our office (other than EDD).
Fees are due at the time the forms are brought to the office. Forms will not be completed before fee is paid.
Please allow 10 business days for processing of all forms.
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
7. MEDICAL RECORDS
AUTHORIZATION TO RELEASE OR RECEIVE CONFIDENTIAL MEDICAL RECORDS
Patient Name
Date of Birth
Doctor requesting/sending records
Doctor or hospital to relinquish or receive records
Address:
Los Alamitos Orthopaedic Medical and Surgical Group
3851 Katella Ave. Suite 150
Los Alamitos, CA 90720
Telephone:
562-314-1400
Fax:
562-431-0564
This authorization to receive/release confidential medical records is to comply with the terms of the appropriate governing codes,
including California civil section 56 et.seq., California evidence code section 115B and other.
The undersigned, hereby authorizes the party listed above to furnish or receive from the above the following requested
medical information:
X-Ray Reports
All Medical Records
X-Ray Films
Laboratory Reports
Other:
This authorization shall become effective immediately and shall remain in effect as long and as necessary the person requesting/receiveing to
fulfill obligations requested.
Photocopy of this authorization shall be considered as valid as the original.
Patient Name
Signature
Date
LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP
8. MEDICATION AGREEMENT
PAIN MEDICATION AGREEMENT
I understand that the doctors at Los Alamitos Orthopaedic Medical & Surgical Group are orthopaedic surgeons, not pain management specialists. The doctor’s goal is
to treat your acute pain as it directly relates to procedures administered by this office. The doctors will do their best to treat your acute pain for a period of 90 days
after which you may be referred to a doctor who specializes in pain management. Surgery patients will be reviewed and treated on a case-by-case basis, staying
within the limits of the law.
The purpose of this Agreement is to prevent misunderstandings about certain medicines you may be taking for acute pain. This is to help both you and your
doctor(s) to comply with the law regarding controlled pharmaceuticals. Doctor(s) and I agree that this agreement is an essential factor in maintaining the trust and
confidence necessary in a doctor/patient relationship. If I fail to abide by the terms of this agreement, it may result in the withdrawal of all prescribed medication
by the Doctor/PA and the termination of the Doctor/Patient relationship.
In this case, Doctor(s) will taper off the medicine over a period of several days, as necessary, to avoid withdrawal symptoms. Also a drug-dependence treatment
program may be recommended.
I will not use any illegal controlled substances, including marijuana, cocaine, etc.
I will not share, sell or trade my medication for money, goods or services.
I will safeguard my medication/prescription from loss or theft and agree that the consequence of my failure to do so is that I will be without
my prescribed medication for a period of time. Lost or stolen medicines/prescriptions will not be replaced.
I agree not to drive or operate heavy equipment while taking pain medication. If I am going to drive, I will agree not to take scheduled medication dose.
I agree that refills of my prescriptions for pain medicine will be made only at the time of an office visit or during regular office hours. No refills will
be available during evenings or on weekends.
I will not attempt to get pain medication from any other health care provider without telling them that I am taking pain medication prescribed by the Doctor/PA. I understand it is against the law to do so. If my primary care physician is willing to prescribe my medications, the Doctor will have to
approve the arrangements to make sure there is no duplication. I will discontinue all previously used pain medications unless told to continue them.
I authorize the doctor(s) and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state’s Board of
Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine. I authorize my doctor to provide a copy of this agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.
I agree that I will submit to a blood or urine test if requested by my doctor(s) to determine my compliance with my program of acute pain
control medicine.
I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being
without medication for a period of time and could possibly cause my death. I realize that all medications have potential side effects and I will have the laboratory studies required to keep the regimen as safe as possible.
I understand that my doctor will review this medication regimen from time to time.
I agree to follow these guidelines that have been fully explained to me. All of my questions and concerns regarding treatment have been adequately answered. A copy of this document has been given to me. I also understand that failure to sign this contract will prevent the doctor/PA from
prescribing any medications.
I agree to use Pharmacy,
located at
Pharmacy number
This agreement is entered into on this
Patient signature
Witnessed by doctor(s) representative
day of
, 20